Healthcare Provider Details

I. General information

NPI: 1023461605
Provider Name (Legal Business Name): ASHLEY ANNE PROULX PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 PINE ST STE 104
BRISTOL CT
06010-6949
US

IV. Provider business mailing address

280 CHESTNUT STREET 2ND FLOOR
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 860-584-8291
  • Fax:
Mailing address:
  • Phone: 413-794-3909
  • Fax: 413-794-1629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3627
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3627
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA6156
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: